Community Development Interventions to Improve Aboriginal Health: Building an Evidence Base

Article excerpt

Introduction

Research on the social determinants of health, specifically 'the social gradient of disease', shows that relative rather than absolute disadvantage is the main cause of health disparity (Marmot 2000; Wilkinson 2002). Exploration of the social gradient of disease suggests one of the most critical psychosocial factors is 'the control factor', which refers to the amount of control people have over their lives, including whether they are part of an integrated social network and have access to supportive relationships (Syme 1998). Despite the undeniable links between social class and population health disparities, public health interventions directly addressing social class as a risk factor, are hard to find (Syme 1998). The complexity of class as a social phenomenon, and the notion of social revolution often associated with the concept, are likely contributing factors to public health practitioners preferring to focus their interventions on individual lifestyle risk factors. Syme (1998) argues that a possible 'solution' lies neither in social revolution nor medicalising social problems for health service intervention. Rather we should focus on aspects of social class which are amenable to change, such as 'control of destiny', and empower individuals and communities to develop the capacity to exert greater control and influence over their social circumstances (Syme 1998, 2003).

Specific social determinants of the poor health of Aboriginal Australians1 include the history of colonisation, poverty, racism, unemployment, lack of education and training, and a lack of access to appropriate health services. Social inequality and relative powerlessness have long been identified as major factors in Aboriginal health and well-being (Devitt et al 2001; Scrimgeour 1997). However, as Tsey and colleagues (2003) observe, 'the question of where to start addressing social determinants of health in Indigenous settings remains a real issue for practitioners in the field'.

Community development and empowerment approaches are considered by Indigenous leaders, Aboriginal Community Controlled Health Services, government departments, public health practitioners and researchers as a key strategy necessary to address the multitude of health problems faced by Aboriginal and Torres Strait Islander people in Australia today (Henry et al 2002). A community development approach can lead directly to improvements in health outcomes by effectively addressing a health issue, or less directly by increasing individual and community empowerment, which leads to healthier and more equitable power relations (Labonte 1994; Baum 2002). This ultimately enables people to have more control over their own health and the health of their communities (Pyett 2002). Conversely, Ife (2002:183) argues that much harm is being done to Aboriginal people often in the name of 'community development', which has been used as a euphemism for '... oppression, domination, colonialism, racism, and the imposition of Western cultural values and traditions at the expense of those of Indigenous people'. Although there is a great need for Aboriginal community development in one sense of the term, Aboriginal people have been victims of this in another sense, for as Ife (2002:183) argues, community development with Aboriginal people is a '... special case, deserving special treatment and careful consideration'.

The complex nature of the social determinants of health and the broad range of interventions labelled 'community development', amplify the need for conceptual clarity about these terms and their interrelationship, particularly in the context of Aboriginal health. There is a great deal of confusion and contention in the literature about the term 'community development' and its constituent concepts of 'community', 'participation' and 'empowerment'. The following definitions were informed by a review of the international and Australian health literature and influenced by new public health and health promotion theory. …